“When I took her to the hospital for an appointment it was in an ambulance, not a car, because one time she almost fell,” explains Jeannette. “It was always a big challenge.”

After Carolina was admitted several times to Markham Stouffville Hospital (MSH) for challenges related to congestive heart failure, an Ontario Health atHome care coordinator suggested a referral to the Seniors Home Support (SHS) program, which would connect her with an interdisciplinary primary care team to support her medical needs at home and help coordinate her ongoing care.

SHS is an integrated primary care program delivered by an interdisciplinary team to home-bound seniors who cannot access office-based primary care services. The care team includes primary care physicians, registered nurses, an occupational therapist, a chiropodist, a pharmacist, community paramedics, and a community care coordinator liaison.

“We deliver timely, comprehensive care to our patients,” says Dr. Annie Cheung, a Primary Care Physician who provides care to SHS patients in Markham and Stouffville. “We also try to help patients and their caregivers navigate the health care system, while addressing their complex needs.”

SHS services were a huge help to Carolina and Jeannette. “I’m alone, I’m her nurse, her caregiver, her daughter, everything,” says Jeannette, adding that, in addition to getting support from a community personal support worker, the home visits from SHS enabled her to provide better care for Carolina. “That helped me go out and do my grocery shopping and do my errands and everything. It helped me with my sanity. Other people may not understand, but for me to go out and see other people and do what I have to do, it’s a huge help. It helped me be a better caregiver.”

An innovative approach

The first home-based program of its kind in Ontario, SHS provides comprehensive primary care for home-bound seniors, delivered through a combination of home visits, telephone support, and virtual consultations.

Referrals to SHS can be made by patients, family members, caregivers, primary care providers, specialists, and community support services. To be eligible for the program, patients must be age 65 or older, have a valid health card, live in Markham or Stouffville, and meet certain criteria in two of three categories—medical, cognitive, and social.

All SHS providers have access to a single electronic medical record for each patient, which improves coordination among practitioners, enhances patient safety, and saves the patient from having to repeat their medical history to numerous providers.

When an SHS-enrolled patient is hospitalized, the team notifies the hospital that they are being followed by a primary care physician and the SHS team. As discharge approaches, the hospital notifies SHS to help anticipate the discharge and coordinate post-hospital care. Many initial referrals to SHS also come from the hospital discharge process.

“My role is to facilitate safe and timely patient discharges, with a strong focus on addressing the ongoing needs of our senior population,” says Sudeep Nair, Patient Flow Coordinator. “Programs like SHS align seamlessly with OVH’s Vision of integrated care for healthier communities. It offers high-quality care in patients’ own homes, reducing unnecessary hospital readmissions and enhancing patient outcomes.”

Partnerships support integrated, patient-centred care

SHS is delivered by partners in Eastern York Region North Durham (EYRND) Ontario Health Team (OHT). Oak Valley Health (OVH) is the largest partner in the EYRND OHT, which connects partners across multiple sectors to develop an integrated system that connects care for patients, families and caregivers in Markham, Stouffville, Thornhill, Brock, and Uxbridge.

EYRND OHT partners providing SHS services are OVH, Markham Family Health Team, York Region Paramedic Services Community Paramedic Program, and Ontario Health atHome. Other EYRND OHT programs include Community Health Clinics in Stouffville and Uxbridge and the Virtual Urgent Care Clinic.

Programs like SHS bring partners together to shape the future of care together. “This model of care is essential as we move toward more integrated and patient-centred care,” says Crystelle Burdeos, a Nurse Navigator who works in SHS. “As the population ages and health care needs become more complex, collaboration is really important.”

Patients and caregivers also appreciate SHS, says Crystelle, adding that “families often express a sense of relief and gratitude. They feel reassured, knowing that care is well-organized, with a team working alongside them to support their loved one’s health and coordinate care as needs change.”

Jeannette agrees, saying she and her mother, who passed away in early 2025, were very pleased with the SHS program. “The doctors and nurses were very helpful,” says Jeannette. “I am so deeply grateful for everything the team has given us.”

Shaping the future: Alongside the EYRND OHT and Ontario Health, work continues to ensure all community members in our catchment, are provided timely access to primary care.